Get Application Cover Page

Filling out the Application Cover Page online can seem daunting, but with clear guidance, you can complete it with confidence. This step-by-step guide will help you navigate the necessary sections of the form effectively.

Follow the steps to complete the Application Cover Page online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the name of the health delivery organization in the designated field. Ensure that you provide the full and official name for clarity.
3. Fill in the mailing address, including street address, city, state, and zip code. Double-check the details for accuracy.
4. Provide the name of the contact person using the appropriate title (Mr., Ms., or Mrs.). This should be the individual who can be reached for further questions regarding the application.
5. Input the contact person's phone number, making sure to include the area code.
6. Enter the contact person's title to specify their role within the organization.
7. Include the contact person's fax number and email address for additional communication options.
8. Indicate the type of health delivery organization by checking the appropriate box for either Hospital, Health System, Integrated Network, or other designated options.
9. Select the primary type of community served by your organization, choosing from urban, rural, suburban, community partnership, other, or mix.
10. List three individuals as references who can attest to your organization’s commitment to community service. For each reference, provide their name, title, organization, city, state, phone number, and their relationship to your health care organization.
11. In the signatures section, type or print the names of the Chief Executive Officer, Board of Trustees Chair, Chief Medical Officer, and Application Contact Person. This confirms that you grant the American Hospital Association permission to use the submitted information.
12. Once you have reviewed the entire form for completeness and accuracy, save your changes, and choose to download, print, or share the Application Cover Page as needed.

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